Barry County Free Carbon Monoxide Program

Fire Departments: Bellevue, Caledonia, Delton, Freeport, Hastings, Hickory Corners, Johnstown, Lake Odessa, Nashville, Orangeville, Prairieville Township, Thornapple Township Emergency Services & Woodland Fire Departments

This program is designed to assist families that are in need of Carbon Monoxide Detectors in their homes.  By signing below you are requesting your area fire department personnel to enter your home and provide an evaluation of your carbon monoxide needs and installation as deemed necessary.  By signing below, recipient agrees to read and follow the carbon monoxide instructions found in the owner=s manual at all times.  By signing below, recipient and anyone acting on his/her behalf knowingly and willingly agrees to fully release, hold harmless, defend and indemnify Barry County United Way, Southside Pediatrics, Pennock Health Services and Pennock Foundation, all fire departments listed above and its employees, together with the officers, employees, agents, successors, assignees, subsidiaries, divisions, and affiliates of these entities from all costs, claims and liabilities which in any way may be related to recipients referral, acquisition and use of the carbon monoxide provided to him/her as part of this offer.

Name ______Address______City & Zip______Phone# ______Best time to reach you______AM or PM Responding Fire Department (if known)______Age of residents in home:______Age of home______# of carbon monoxide detectors currently in home ______Do you own rent your home (rental units do not qualify for this program, please contact your landlord) I attest to the validity of all information above Signature______Date______

For Fire Department use only Fire Department ______Fire Personnel names ______# of carbon monoxide detectors checked ______# of carbon monoxide detectors installed______other______

I, the homeowner/renter of this home at the above address understand the information I have been given and agree to keep the carbon monoxide detector in working order. ______Date______

Return application to Barry County United Way - 231 S. Broadway, Hastings, MI 49058 or FAX to (269)945-4536, or your local fire department. If you have any questions, please call Barry County United Way at (269)945-4010.